2014 Annual Inspection Form - DRAFT Pass Fail Pass Fail Pass Fail Pass Fail Interstitial Monitoring Pass Fail Pass Fail Pass Fail Pass Fail UST-01 Rev Date: 08/24/20 Dispenser Area

Underground Oil Storage Tanks

Annual Inspection Report

Rev 8/24/2020

General Instructions

1. State law and Department of Environmental Protection (Department) rules require submittal of an inspection

certifying all procedures and equipment are in compliance. The Department does not accept failing annual

inspections.

Exceptions : Inspection failures for (1) Certified A/B Operator can be resolved by the owner by submitting a

copy of a current and valid certificate; (2) Inadequate daily inventory can be resolved by the owner submitting

current, reconciled daily inventory; (3) Inadequate SIR Report can be reloved by the owner submitting a

passing SIR report; and (4) Failing cathodic protection (CP) results can be resolved by an installer or CP

certified inspector retesting CP and attaining passing results within six months.

2. A facility that fails to submit a passing annual inspection may be prohibited from receiving deliveries and

dispensing product in accordance with Maine law 38 M.R.S. § 565-A. Items that are failing must be repaired or

corrected within thirty (30) days or the owner must notify the Department.

3. Leak detection equipment and procedures, spill and overfill prevention devices must be checked or tested

annually for proper operation. Cathodically protected tanks and piping must be checked annually to insure they

are adequately protected from corrosion.

4. All work associated with testing of equipment and checking of procedures must be performed by or under the

direct, onsite supervision of a Maine certified underground storage tank installer or a Maine certified

underground storage tank inspector.

5. Mail completed reports to: Annual Tank Inspections, Maine Department of Environmental Protection, 17 State

House Station, Augusta, Maine 04333-0017 (physical address: 28 Tyson Drive, 04330) within thirty (30) days

after the inspection is completed. The owner/operator must retain a copy.

6. Detailed instructions on how to fill out this form are provided in the Department's “UST Inspector Reference

Handbook”, available online at www.maine.gov/dep/waste/ust/pubs.html. The Annual Inspection Report form,

the Inspector Reference Handbook and a list of Frequently Asked Questions (FAQ’s) are also available by

calling the Underground Tanks Unit at (207) 287-7688.

To Installers and Inspectors: This electronic document (the overall workbook and each individual inspection

worksheet) is password protected so that formulas and function in certain cells cannot be changed outside

of the DEP. If you find errors in this workbook, need something clarified, have a suggestion on how to

improve the form, or would like to include your business logo or make a similar addition to the form, please

contact the DEP at 207-287-7688 and ask to speak with someone in the Underground Tanks Unit.

Form Instructions

Underground Oil Storage Tanks

Annual Inspection Report

SPECIAL INSTRUCTIONS

1 General instructions covering Annual Inspection requirements are located in the Annual Inspection Owner/Operator

Guide , a separate document. Instructions for completing the Annual Inspection Report form are located in the UST

Inspector Reference Handbook . The special instructions contained in this page are designed to be used in conjunction

with, and to enhance the instructions of, the Handbook. These instructions will also provide a guide to functions that are

specific to this Microsoft Excel workbook.

2 This workbook contains all pages of the Annual Inspection Report form (Page 1: Summary through Page 9: Temporarily

Out-of-Service Tanks ). It also contains two instruction pages and a copy of the Weekly Walkthrough Inspection

Checklist. Each page is accessed by clicking on the color-coded tabs at the bottom of the workbook:

= Form Instructions (two printed pages)

= Guidance Document (for facility owners and/or operators)

= Page 1: Summary

= Pages 2-9: Inspection Checklist worksheets

3 Information can only be entered into cells (blocks) that are NOT shaded.

4 On all pages, blocks that are shaded light yellow cannot be filled in by the user. These shaded blocks are automatically

filled in by the Excel program based on other entrees made in the form. For example: A CTI inspects a facility with only

one tank and finds that the tank's ball float is not set at 90% tank capacity. The CTI then places an "X" in appropriate

FAIL block (page 6, Item 41, cell block I15). The Excel program will then automatically place an "X" in the light-yellow

"Overfill Prevention" FAIL box below Item 42 (cell block I17) and also place an "X" in the "Overfill Prevention" FAIL box

for that tank on the Summary Page.

5 Please use only the letter "X" when filling in any PASS, FAIL, Yes or No check-box. It doesn't matter if the "X" is

capitalized or a small letter.

SUMMARY PAGE ONLY

6 Much of the information that a user enters on Page 1, Summary Page is automatically copied into appropriate cells

(blocks) in the separate worksheet checklists. For example, the facility registration number and inspection date are

copied and placed on the top of each subsequent inspection page. The tank/chamber number, volume, and product

contained in a tank are also copied and pasted into pages where the information is needed.

7 Each PASS block on the Summary page must be manually filled in (of course, this is only if the appropriate section in the

inspection page warrants a PASS on the summary page!)

WORKSHEET CHECKLISTS

8 An "X" that is placed in any "FAIL" box in an individual inspection page (pages 3 through 9) will automatically update the

appropriate overall "FAIL" boxes in the Summary Page (page 1).

9 "Pass" blocks must be manually filled-in, where appropriate, on each page; there is NO automatic copying of any "Pass"

to the Summary Page (page 1)

10 Use the key sequence: to start a new line in any "Comments" block; using just the key will close

the editing session in the "Comments" block and move you to the next open fill-in block.

11 If you need additional space for written comments, or in the case of page 6 where there is no comments section, use any

other comments box on any page. Please start each comment with the inspection item number to which the comment

refers.

1 2 3 4 5

Date of Inspection:

Release Detection:

● Is the Electronic system working properly?

● Is daily inventory being maintained and properly

reconciled monthly?

● Is the Manual Groundwater or Tank Interstitial Space

Log being maintained?

Electronic Overfill Alarm (if equipped): Inspect/test for

proper operation. Can a fuel delivery person hear and see

the alarm when it alarms?

Spill Log: Is the spill log properly used and maintained?

Spill Buckets: Are spill buckets clean and empty?

Spill And Overfill Response Supplies: Inventory the emergency spill response supplies. If the supplies are low,

restock the supplies. Are supplies adequate?

Fill And Monitoring Ports: Inspect all fill, monitoring and vapor recovery ports. Are covers and caps tightly sealed with no

damage?

Dispenser Area: Check the dispenser islands and surrounding areas. Are these areas free of evidence of spills and discharges?

Clean areas as needed.

Dispensers And Dispenser Sumps: Open each dispenser

cabinet and inspect all piping, fittings, and couplings for

signs of leakage. Are the sumps free of any water, product

or debris? (Remove any liquid or debris and disposed of

properly)

Dispenser Hoses, Nozzles, and Breakaways: Are fittings tight and functioning properly? Are hoses in good condition (not

cracked or showing any wear)?

UST-28 REV: November 2017

This checklist may be used by certified Class A/B Operators to perform weekly inspections at underground storage tank

facilities. This checklist, when properly completed, will be accepted by the Maine Department of Environmental Protection

as demonstrating compliance with the weekly inspection requirements of 06-096 C.M.R., Chapter 693, Operator

Training for Underground Oil and Hazardous Substance Storage Facilities .

You should be able to answer “yes” to each question. Your initials in each box below the inspection date indicates the

device/system was inspected, is operating properly and is compliant with the requirements.

On the back of this form, date and describe any actions taken to correct an issue.

State of Maine

Department of Environmental Protection

Underground Oil Storage Facility - Class A/B Operator

Weekly Walk-Through Inspection Checklist

Month / Year: _______________________Facility Name & Reg # _______________________________

Maine Department of Environmental Protection 17 State House Station • Augusta, Maine • 04333-0017 • (207) 287-7688

UST Program Website: www.rnaine.gov/dep/waste/ust

Requirements for Unattended Fueling and Signage

Requirements f